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<meta name="description" content="龋病总结1.龋病的诊断：①一般诊断方法：问诊：症状，病史。视诊：观察患牙的色形质，a.色：清洁牙面，吹干，在光线良好情况下进行。观察有无牙面白垩色或黑褐色改变，有无墨浸样改变。b.形：有无实质缺损，有无龋洞。探诊：探针探诊，患区牙体光滑度，质地，连续性，如果探知牙面粗糙、连续性消失、探针被卡住或牙组织变软，均提示牙体存在着实质缺损和龋坏。叩诊：应为阴性。②特殊检查方法：X片检查：最好用咬合翼片，避">
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        <p>龋病总结<br>1.龋病的诊断：<br>①一般诊断方法：<br>问诊：症状，病史。<br>视诊：观察患牙的色形质，a.色：清洁牙面，吹干，在光线良好情况下进行。观察有无牙面白垩色或黑褐色改变，有无墨浸样改变。b.形：有无实质缺损，有无龋洞。<br>探诊：探针探诊，患区牙体光滑度，质地，连续性，如果探知牙面粗糙、连续性消失、探针被卡住或牙组织变软，均提示牙体存在着实质缺损和龋坏。<br>叩诊：应为阴性。<br>②特殊检查方法：<br>X片检查：最好用咬合翼片，避免影像重叠。在X线片上显示的密度一般较周围正常牙体组织低，呈现透射影像。<br>牙髓活力测试：同对照牙，深龋有一过性敏感。<br>③浅龋与正常窝沟的鉴别：窝沟正常情况下也有黑褐色色素沉着，但着色不弥散，而已有浅龋的窝沟则呈墨浸状。探诊正常窝沟，尖头探针不易插入，而龋坏窝沟较易插入，且易勾挂住探针尖，还可探查到沟底的质地较软，有粘嘬住探针的感觉。对有些较深的窝沟，一时难以鉴别，可视为可疑龋，定期观察。（一定有一些正常窝沟被当成浅龋补掉啦。关键看质地。）<br>根据情况选择诊断标准<br>严格的诊断标准：①牙本质龋患病率低；②充填体维持时间短；③非手术治疗不会导致严重的并发症(如龋病快速进展，牙痛或牙髓治疗）。<br>不太严格的诊断标准：①牙本质龋患病率高；②充填体维持时间长；③非手术治疗会导致严重并发症。<br>静止龋并不需要治疗。事实上，对静止龋的治疗是时间与资金的浪费。<br>实操一下，拔下来的离体牙，基本都是智齿。<br>一个邻面洞，一个牙合面洞。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/01.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/02.jpg"><br>双氧水泡过，所以邻面龋坏不明显，挖匙上去是软的。<br>2.龋病的手术治疗：<br>进行牙体修复的最重要原因是辅助菌斑控制，另外的原因：患牙对冷、热、甜敏感；对牙髓构成危险；曾尝试终止龋病发展结果失败，并且有迹象表明龋损在继续发展；功能被削弱；由于邻接关系的丧失，患牙可能会松动；美观因素。<br>龋损部位分类：<br>1类：龋损发生于任何患牙的点隙窝沟。<br>2类：龋损发生于前磨牙和磨牙的邻面。<br>3类：龋损发生于切牙和尖牙的邻面，未累及切角。<br>4类：龋损发生于切牙的邻面，累及切角。<br>5类：龋损发生于患牙的唇颊或舌面的龈1/3，不包括点隙窝沟龋损。<br>修复治疗的目的：①控制特定部位的生物膜和龋活跃性；②利用粘接材料封闭冠部保护牙髓-牙本质复合体，终止龋损活跃性；③恢复牙齿的功能、形态及美观。<br>关键步骤是去龋。<br>基于循证医学，去龋的目的是为修复体提供足够的粘接以延长修复体的寿命。<br>对深龋（影像学上龋损已达牙本质的近髓1/3或1/4，或有牙髓暴露的风险），应优先保护牙髓健康。对于浅层或中层深龋（影像学上未达牙本质近髓1/3或1/4），延长修复体寿命更加重要。<br>龋坏牙本质分类：<br>①软化牙本质：在牙科器械加压时发生变形，使用尖锐的手用挖器用很小的力量即可刮除软化牙本质。<br>②皮革化牙本质：在牙科器械加压时不变形，无需太大力量即可被去除。皮革化牙本质是软化牙本质和韧化牙本质之间的一种过渡，与韧化牙本质的区别很小。一般只出现在龋活跃性较低或龋损已停止的龋洞内。<br>③韧化牙本质：在手用挖器刮除时有抵抗力，需要一定的力量才能去除。<br>④硬化牙本质：硬器械探查时需要加压，仅锋利器械或牙钻可以去除。探针加压划过牙本质时可以听到刺耳的刮擦音。<br>牙本质类型<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/03.jpg"><br>选择性去龋的标准：窝洞边缘预备至健康牙釉质，窝洞侧壁预备至硬化牙本质。窝洞髓壁去龋止点可根据龋损深度确定：X线片上龋损未超过牙本质近髓1/3或1/4，预备至韧化牙本质；X线片上龋损超过牙本质近髓1/3或1/4，可保留软化牙本质，以避免牙髓暴露。<br>对髓壁龋坏的处理：<br>深龋的判断标准：影像学显示龋损超过牙本质近髓1/3或1/4。（具体是1/3还是1/4，我的理解是根据临床情况灵活掌握，激进一点就选1/4，保守一点就选1/3）<br>浅、中龋：去除皮革化牙本质，保留韧化牙本质。<br>深龋：选择性去龋。<br>①去龋至髓壁保留近髓处软化牙本质，以避免露髓，保留牙髓活力。<br>②将去龋分两步完成。第一次治疗时，保留近髓软化牙本质，侧壁去龋至硬化牙本质，以利于完全和持久的窝洞密封。窝洞暂时封闭6个月，最长封闭时间为12个月。第二次复诊时，去除充填材料，去除第一次残留的龋坏牙本质至皮革化牙本质。<br>没有证据支持窝洞消毒和衬洞。<br>去龋后的照片，邻面洞这个看着蛮干净，挖匙上去还是软的，把软的去干净，有穿髓点了。就做直接盖髓了吧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/04.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/05.jpg"><br>窝洞预备<br>窝洞分类：<br>Ⅰ 类：龋损发生在牙体发育点隙沟裂内所制备的窝洞。包括磨牙和前磨牙咬合面的点隙沟裂洞，下磨牙颊面和上磨牙腭面的沟、切牙舌面窝内的洞。<br>Ⅱ类：龋损发生在前磨牙和磨牙邻面所制备的洞。如邻面龋损破坏到咬合面所制备的窝洞。<br>Ⅲ类：龋损发生在前牙邻面所制备的洞。如病变扩大到牙的舌面或唇面，所制备的洞也属于此类。<br>Ⅳ类：龋损发生在前牙邻面并破坏了切角所制备的洞。<br>Ⅴ类：龋损发生在所有牙唇、舌、颊面颈1/3区域所制备的洞，但未累及该面的点隙沟裂者。<br>牙体缺损修复治疗的洞形预备越来越趋于保守。<br>在洞形设计时尽量避开咬合接触部位，尽可能保留患牙原有的生理牙合面形态，即功能牙尖斜面，尽量少破坏患牙的正中牙合和侧方牙合运动轨迹，避免因充填修复治疗造成新的牙合干扰。<br>当牙本质缺失时，无机釉质受力极易崩失。大多数学者主张备洞时去除无机釉。在牙体缺损修复治疗过程中要避免过度磨除牙本质，以免人为造成新的无基釉。对于美观功能要求高而承受牙合力较小的前牙充填修复部位，可适当保留无基釉，采用粘接修复术保证充填修复体的美观性能。<br>前牙釉质可以预备短斜面，后牙不必。充填体边缘不要放在咬合接触点上。<br>粘接：<br>四代：全酸蚀，去除玷污层，酸蚀-预处理-粘接。<br>五代：全酸蚀，去除玷污层，酸蚀、预处理+粘接。<br>六代：自酸蚀，玷污层改性，酸蚀+预处理、粘接。<br>七代：自酸蚀，玷污层改性，酸蚀+预处理+粘接。<br>八代：通用，单组分。<br>我现在用的还是第六代可乐丽SE Bond，先写这个的步骤。订的第八代的还没来。<br>操作方法：窝洞预备，涂布处理剂，等20秒，中等空气干燥，涂粘接剂，空气轻轻吹干，光固化10秒，充填。现在我临床操作还加一个选择性酸蚀釉质的步骤，时间15秒。<br>如果是二类洞，要使用成型系统。 豆瓣成型片与传统成型片相比能形成更好的邻接接触。圆环的脚要放在成型片与楔子之间。<br>树脂充填：<br>树脂的选择，我用的主要就3M的Z250XT, Z350XT, P60三种了。<br>Z250XT是纳米填料树脂，Z350XT是它的改进，二者前后牙通用。P60是混合微填料，用于后牙，抛光性能差一些。<br>色度最强烈的区域是牙齿的龈方区域，因为这里牙釉质最薄，能透出更多的牙本质。<br>体部区域是混合着牙本质色和轻微的牙釉质色以及表面形态。文献建议体部的色度要比龈方区域的颜色低一两个等级。<br>切端区域因为牙本质的量的减少要，透明度要更高。<br>逐层充填，每层不超过2.5mm，光固化20秒。<br>实操图片<br>先对邻面洞穿髓点，用光固化氢氧化钙（钙思莫）直接盖髓。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/06.jpg"><br>对两颗牙牙釉质进行选择性酸蚀，时间15秒。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/07.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/08.jpg"><br>酸蚀后，水跟气冲洗15s，吹干。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/09.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/10.jpg"><br>涂粘接剂，用的可乐丽SE BOND，六代自酸蚀粘接剂。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/11.jpg"><br>依次涂预处理剂20s，吹干，涂粘接剂20s，不停涂擦，吹干。（邻面洞那个粘接剂多涂了一些时间，预防术后敏感）光固化10秒，完了以后表面是光亮的，但没有液体流动。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/12.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/13.jpg"><br>邻面洞洞比较深，先用3M流动树脂垫底。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/14.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/15.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/16.jpg"><br>用3M P60复合树脂分层充填。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/17.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/18.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/19.jpg"><br>邻面洞充填完成<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/20.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/21.jpg"><br>充填牙合面洞<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/22.jpg"><br>有个技巧，如果树脂粘器械（Z250和Z350容易粘），或者边缘不好处理，可以用沾粘接剂的小毛刷去按。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/23.jpg"><br>充填完成的<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/24.jpg"><br>在口外，调合就略了。抛光的东西也没有到。<br>颌面洞这颗牙的牙根好奇特，留着练习做根管吧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0040-qbzj/25.jpg"></p>
<p>没有邻牙，成型片不好放，就不演示了。临床实操吧。<br>充填后调合：<br>树脂充填后调合顺序：正中、侧方、前伸、协调前导。不是只调正中咬合没有高点就完了。也不是所有印迹都要磨。调前伸颌、侧方颌时要使后牙没有滑动接触。方法是用两种颜色的咬合纸，一种记录正中牙合，另一种调非正中牙合。调完以后要仔细检查。<br>抛光：<br>在抛光顺序中，跳过任何抛光粒度，都有可能降低修复体的抛光质量。<br>有色码的，包括从暗色（较粗的颗粒）至浅色（较细的磨料）。<br>使用轻压力，每个抛光碟使用15-20秒。<br>抛光未必能减少边缘微渗漏（这主要跟树脂本身有关），但能降低菌斑的黏附，口感也更好。</p>
<p>充填体使用寿命的问题：<br>每年失败率约2%-4%，10年的存留率在60%以上。充填失败的原因，在充填初期是牙髓病变，随着时间的推移，主要原因变为充填体/牙体折裂和继发龋。影响失败率的因素有患者患龋风险，充填体的面数，术者操作等，而通常患者关注的充填材料，以及医生关心的粘接技术等则无明显影响。</p>
<p>第一次尝试这种学习方式：针对一个自己感兴趣的领域，提出一些问题，然后查各种信息，来回答这些问题，最后实践。自己感觉蛮有效的。其实我一开始提的好多问题是我临床上一直都有的疑惑，但是因为没有直接影响操作，反正还能对付过去，我就没去深究了。以后不能像这样了。2014年我在原东家那里的时候参加了一个内部的学习班，其中一位老师在最后讲到了继续教育的学习效果：看书、找资料、自学&lt;学术讲座、会议&lt;交费学习班&lt;有的放矢的循证。当时把这句话记住了，但是仅此而已，并没有行动。现在自己真的想把专业整好，起码要合格吧，才觉得真是这样。继续加油吧。下一步打算总结根管治疗的东西了。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>
<p>总的参考资料:</p>
<ol>
<li>《龋病学：疾病及其临床处理》，Ole Fejerskov，Edwina Kidd著，樊明文，边专主译，人民卫生出版社，2006年3月第一版</li>
<li>《临床龋病学》，高学军主编，北京大学医学出版社，2013年9月第2版</li>
<li>《实用龋病学》，周学东、岳松龄主编，人民卫生出版社，2008年11月第1版</li>
<li>陈智 卢展民.龋损管理：龋坏组织去除的专家共识.中华口腔医学杂志，2016年12月,51(12):712-716.</li>
<li>F.Schwedicke, J.E.Frencken, et al. Managing Carious Lesions:Consensus Recommendations on Carious Tissus Removal. Advances in Dental Research 2016, Vol. 28(2) 58-67.   DOI:10.1177/0022034516639271</li>
<li>《牙体牙髓病学》,高学军 岳林.北京大学医学出版社.2013年12月第2版.</li>
<li>刘战义,王怡莹,何晓丽.复合树脂充填体受不同方向力时固位差异分析.口腔颌面修复学杂志,2018年1月，19(1):19-21.</li>
<li>Greene Vardiman Black. <a target="_blank" rel="noopener" href="https://en.wikipedia.org/wiki/Greene_Vardiman_Black">https://en.wikipedia.org/wiki/Greene_Vardiman_Black</a></li>
<li>Dr. GV Black History. <a target="_blank" rel="noopener" href="http://www.gvblackdentalsociety.org/about-us/dr-gv-black-history">http://www.gvblackdentalsociety.org/about-us/dr-gv-black-history</a></li>
<li>樊明文.复合树脂多层美学修复：基础理论与临床.人民卫生出版社.2011年10月第一版第一刷.</li>
<li>3M ESPE. Adper Single Bond2 Adhesive说明书. <a target="_blank" rel="noopener" href="http://multimedia.3m.com/mws/media/276868O/adper-single-bond-2-technical-profile.pdf">http://multimedia.3m.com/mws/media/276868O/adper-single-bond-2-technical-profile.pdf</a></li>
<li>3M ESPE. Adper Easy One Self-Etch Adhesive说明书.  <a target="_blank" rel="noopener" href="http://multimedia.3m.com/mws/media/651318O/adper-easy-one-one-for-all-cee.pdf?fn=Adper_EasyO_Oneforall_F_CEE.pdf">http://multimedia.3m.com/mws/media/651318O/adper-easy-one-one-for-all-cee.pdf?fn=Adper_EasyO_Oneforall_F_CEE.pdf</a></li>
<li>3M ESPE.Single Bond Universal Adhesive Technical Product Profile.  <a target="_blank" rel="noopener" href="http://dentistofthefuture.3m.com/Upload/AttachFile/e2369cc5-933e-4fa3-b7f8-d6cdb221d3b7/SBU_TPP.pdf">http://dentistofthefuture.3m.com/Upload/AttachFile/e2369cc5-933e-4fa3-b7f8-d6cdb221d3b7/SBU_TPP.pdf</a></li>
<li>3M ESPE.Scotchbond Universal Adhesive Dispensing Technique Guide. <a target="_blank" rel="noopener" href="https://multimedia.3m.com/mws/media/755849O/scotchbond-universal-adhesive.pdf">https://multimedia.3m.com/mws/media/755849O/scotchbond-universal-adhesive.pdf</a></li>
<li>日进公司.齿科树脂粘接剂使用说明书.<a target="_blank" rel="noopener" href="http://www.nissin-dental.cn/upload/file/download/%E9%BD%BF%E7%A7%91SuperBond%E8%B6%85%E7%BA%A7%E7%B2%98%E6%8E%A5%E5%89%82%E4%BD%BF%E7%94%A8%E8%AF%B4%E6%98%8E%E4%B9%A6.pdf">http://www.nissin-dental.cn/upload/file/download/%E9%BD%BF%E7%A7%91SuperBond%E8%B6%85%E7%BA%A7%E7%B2%98%E6%8E%A5%E5%89%82%E4%BD%BF%E7%94%A8%E8%AF%B4%E6%98%8E%E4%B9%A6.pdf</a></li>
<li>Kerr公司.OptiBond Solo Plus Instruction For Use. <a target="_blank" rel="noopener" href="https://www.kerrdental.com/resource-center/optibond-solo-plus-instructions-use">https://www.kerrdental.com/resource-center/optibond-solo-plus-instructions-use</a></li>
<li>Ivoclar Vivadent.牙本质牙釉质粘接剂(Syntac)使用说明书.  <a target="_blank" rel="noopener" href="http://www.ivoclarvivadent.cn/cn/dental-professional/total-etch-adhesives/syntac">http://www.ivoclarvivadent.cn/cn/dental-professional/total-etch-adhesives/syntac</a></li>
<li>Ivoclar Vivadent.牙科粘接剂（Tetric N-Bond）使用说明书.  <a target="_blank" rel="noopener" href="http://www.ivoclarvivadent.cn/cn/dental-professional/total-etch-adhesives/tetric-n-bond">http://www.ivoclarvivadent.cn/cn/dental-professional/total-etch-adhesives/tetric-n-bond</a></li>
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